Failure to Provide Special Dietary Needs
Summary
The facility failed to provide special dietary needs for three residents during a lunch meal preparation. Resident 46 and Resident 76, who were both on a puree - level 4, fortified diet, were initially served regular pureed chili instead of the fortified version. This discrepancy was identified during the meal preparation, and the dietary staff corrected the error by replacing the regular chili with fortified chili. The Registered Dietitian confirmed that the residents should have received fortified chili to meet their nutritional requirements. Resident 192, who was on a dysphagia mechanical soft diet and had specific dislikes for toast, bread, and rice, was served a meal without a starch component. The Dietary Supervisor initially justified the omission by stating that the resident usually finished the meal without the starch and had other food items like yogurt and milk to supplement intake. However, it was later acknowledged that an alternative starch component should have been provided, and mashed potatoes were prepared for the resident. The facility's policy indicated that menus should meet the nutritional needs of residents using established national guidelines.
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Multiple residents with significant medical conditions, including stroke, COPD, heart failure, and muscle weakness, consistently received breakfast oatmeal that was cold, lumpy, thick, and sometimes removable from the bowl in a single solid mass. Several residents refused to eat the oatmeal due to its poor quality, while one cognitively impaired resident ate it despite acknowledging it was cold and lumpy. A CNA reported that the oatmeal was always served this way, that many residents complained, and that she had informed the kitchen without any change, sometimes mixing the cold oatmeal with warm eggs to encourage intake. Another resident reported routinely requesting extra toast instead of eating the oatmeal and stated she had told CNAs about the issue. The Dietary Manager stated the oatmeal left the kitchen warm and was unaware of grievances, and the Administrator and DON reported they were not aware of any oatmeal problems, despite the facility’s policy requiring food to be prepared according to applicable food service regulations.
During a multi-day power outage, the facility relied only on a gas stove, leaving kitchen equipment such as the food processor unusable and resulting in residents on pureed diets receiving limited items like mashed potatoes, stuffing, tomato soup, and cream of wheat without clear protein sources. Several residents with dysphagia, protein-calorie malnutrition, significant weight loss, COPD, and other chronic conditions had orders for pureed diets and nutritional supplements, but documentation in progress notes, intake records, and MARs did not show that any additional supplementation beyond routine orders was provided during the outage. Dietary staff could not specify what protein foods were served, no records were kept of the actual foods provided, tray tickets did not list what was served, and one resident reported not getting enough to eat or receiving extra items such as shakes or ice cream. The DON and RD could not verify that residents on pureed diets received well-balanced, protein-adequate meals during this emergency period.
The facility failed to provide ordered meals, supplements, and adequate feeding assistance to several cognitively intact but fully dependent residents. One resident with quadriplegia, malnutrition, and pressure ulcers reported often receiving only one meal per day, not being awakened or assisted for meals, and not consistently receiving prescribed supplements. Another resident with quadriplegia and severe protein-calorie malnutrition stated that staff did not always wake him for meals, that multiple meals were missed when he was sleeping, and that he felt rushed when being fed. A third resident with quadriplegia and diabetes reported relying on staff for feeding, sometimes not receiving her meal tray because it was left on the cart and returned to the kitchen, and on one occasion being told the kitchen was closed so she received nothing to eat. Staff interviews described problems with feeding during shift change, residents reporting missed meals, and communication failures that led to meal tickets not being printed for residents who had returned from the hospital.
The facility failed to follow a resident’s diet order for double vegetable portions and large breakfast portions, despite a policy requiring menus and meals to meet residents’ nutritional needs and be served as written. A resident with a consistent carbohydrate diet order did not have the double vegetable portion instruction printed on tray tickets, and was observed receiving the same number of potato wedges as other residents. The Dietary Manager confirmed that extra portion orders should appear on tray tickets and acknowledged that this resident’s tickets previously included, but no longer showed, the extra portion instructions.
A resident with impaired cognition, blindness, and multiple conditions including Type II DM, hypothyroidism, hypokalemia, and adult failure to thrive was care planned to require feeding assistance, meal setup using a clock system, and monitoring of nutritional intake. During an observed lunch meal service, meal trays were delivered on the hall and to rooms, but the resident did not receive a lunch tray over an extended period. A CNA, unfamiliar with the facility and residents, did not verify that all residents had trays, and an RN reported that the resident typically refused meals and preferred Cheerios, confirming that no lunch tray was offered.
A resident admitted in the early evening with fracture pelvis, respiratory failure, and protein-calorie malnutrition, and ordered a regular mechanical soft diet, did not receive an evening meal from the facility. The family member reported that no staff offered food, a nurse stated the kitchen was closed, and the family had to purchase food from a local restaurant. The Dietary Manager stated that admission memos had prompted preparation of several trays, including one left in the kitchen window for this resident, but nursing never retrieved or delivered it. The tray remained in the window until the next morning, and the resident later reported being hungry and receiving little to eat for supper.
Cold, Unpalatable Oatmeal Served Repeatedly at Breakfast
Penalty
Summary
The facility failed to provide a nourishing, palatable, well-balanced diet that met residents’ daily nutritional and special dietary needs and preferences, specifically related to the breakfast oatmeal served to multiple residents. Surveyors reviewed records for four residents and observed breakfast service on Hall 200. Resident #1, an elderly female with severe cognitive impairment and diagnoses including cerebral infarction, chronic respiratory failure, and atrial fibrillation, was observed eating oatmeal in bed; she stated she knew the oatmeal was cold and lumpy but was eating it because she was hungry. The oatmeal appeared sticky, and when the bowl was touched it was cold. Resident #1 later stated she did not mind cold food and would try to eat anything, but acknowledged the oatmeal would taste better if it were warm. Resident #2, an elderly male with cerebral infarction, hypertension, and edema who was alert, oriented, and able to make decisions, was observed in the same room as Resident #1. He had eaten the rest of his breakfast but refused to eat the oatmeal, stating it was sticky, cold, lumpy, and looked disgusting, and that it was always served that way. He demonstrated that the oatmeal could be lifted from the bowl in one whole piece. Resident #3, an elderly male with COPD, heart failure, and congestive heart failure who was also alert and oriented, had finished his eggs and toast but had not touched his oatmeal. He stated he could not eat the oatmeal because it was terrible, always thick and cold, and showed that the entire bowl of oatmeal came out in one piece when he tried to stir it. He reported that he had told staff about the problem but nothing had changed. Resident #4, an elderly female with cerebral infarction, hypertension, and muscle weakness who was alert and oriented, stated during breakfast that she would like her oatmeal to be warm and edible. She reported that the oatmeal was always served cold, sticky, and in one big lump, so she asked for extra toast instead, and said she had told CNAs but did not like to make a fuss. CNA A confirmed during interview that the oatmeal was always served lumpy and cold, that many residents complained, and that although she had informed the kitchen, nothing had changed. CNA A stated she tried to mix the cold oatmeal with warm eggs for Resident #1 and that residents declined offers of fresh oatmeal because they believed it would be the same. The Dietary Manager stated the oatmeal left the kitchen warm and she did not know what happened afterward, and reported no recollection of grievances about cold, inedible oatmeal. The Administrator and DON stated they were unaware of any problems with the oatmeal. The facility’s Dietary Services Meal and Food policy stated that food prepared for residents is to be prepared according to all applicable food service regulations.
Failure to Ensure Adequate Pureed Diet Nutrition During Power Outage
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents received a nourishing, palatable, well‑balanced diet that met daily nutritional and special dietary needs during a prolonged power outage. The facility experienced a power outage from the evening of 03/13/26 until the morning of 03/15/26, during which only the gas stove functioned in the kitchen because there were no generator-connected (red) outlets. As a result, staff could not use the food processor to prepare pureed foods and instead served items that could be made with boiling water. Dietary staff reported that residents on pureed diets were given mashed potatoes, stuffing, tomato soup, and cream of wheat, and no record was kept of the specific foods served during this period. Tray tickets for affected meals did not indicate what foods were actually provided. Four residents with orders for pureed diet textures were specifically reviewed. One resident had dementia, type 2 diabetes mellitus, dysphagia oral phase, and was care planned as at risk for nutritional decline, with interventions including pureed diet with thickened liquids and house supplements twice daily. Another resident had protein calorie malnutrition, muscle wasting and atrophy, diverticulosis, and a history of significant weight loss, and was also care planned for pureed texture and house supplements twice daily. A third resident had dysphagia oropharyngeal phase, respiratory failure, intellectual disabilities, adult failure to thrive, and was ordered a pureed diet with nectar thick liquids and a daily house supplement. The fourth resident had COPD, GERD, mild cognitive impairment, major depressive disorder, significant weight loss, and was ordered a pureed diet with nectar thick liquids, Magic Cup with meals, and house supplements with meals for weight loss. For all four residents, review of progress notes, nurse aide intake tracking, and MARs showed no documentation that any additional supplementation beyond the routinely scheduled supplements was provided during the power outage dates. Dietary staff, including the Dietary Supervisor and Dietary Director, were unable to identify what protein sources were served to residents on pureed diets during this time. A DTR and a Regional RN asserted that residents on pureed diets received nutritional supplements and that items such as tomato soup provided some protein, but the RD could not confirm whether additional supplementation was actually provided during the outage. One cognitively intact resident reported not getting enough to eat during the outage and stated that, although some food was provided, it was not enough to satisfy hunger and no additional items like ice cream or health shakes were offered. The DON confirmed that tray tickets did not specify what foods were served during the power outage, and there was no documentation to substantiate that residents on pureed diets received balanced meals or adequate protein during this emergency period. The deficiency affected four reviewed residents with pureed diet orders and had the potential to affect all eight residents in the facility who required pureed diet textures. The lack of a system to ensure well‑balanced, nutritionally adequate pureed meals during the power outage, combined with the absence of documentation of what foods and supplements were actually provided, led to the finding that the facility did not meet the requirement to provide each resident with a diet that met daily nutritional and special dietary needs during the emergency event.
Failure to Provide Ordered Meals, Supplements, and Feeding Assistance to Dependent Residents
Penalty
Summary
The facility failed to provide nourishing, palatable, well-balanced diets and supplements as ordered and to ensure necessary feeding assistance for three dependent residents. Facility policy stated that clients are to be served their diets as ordered, and care plans and MDS assessments documented that these residents were cognitively intact but dependent on staff for all activities of daily living, including feeding. For one resident with quadriplegia, chronic kidney disease, neuromuscular dysfunction, pressure ulcers, anorexia, malnutrition, and an inability to feed himself, the care plan directed staff to feed all meals and give supplements as prescribed. This resident reported usually only getting to eat one meal a day, that staff sometimes did not come to feed him, and that if he was asleep staff would not wake him to feed him. He also stated he did not receive his ordered supplements very often or every day and denied refusing them. Another resident with quadriplegia, severe protein-calorie malnutrition (on hospice), low BMI, depression, and a stage 4 sacral pressure ulcer was also documented as cognitively intact and dependent on staff for all ADLs. His care plan included providing and serving diet as ordered. He reported that he sleeps a lot and that staff did not always wake him to feed him if he was asleep. He further stated that two of six meals over a weekend were missed because he was sleeping and no one returned to feed him, and that when he was fed he felt rushed, which caused him to feel full too quickly. A third resident with type 2 diabetes mellitus, quadriplegia, hypertension, major depressive disorder, cognitive communication deficit, and osteoporosis, also cognitively intact and fully dependent on staff, reported relying on staff for feeding and usually being fed only after all trays were passed on the hall. She stated there were two occasions in recent weeks when she did not receive her meal tray because it remained on the cart and was returned to the kitchen. On one of those occasions, after she asked a CNA and an agency nurse to retrieve the tray, they told her the kitchen was already shut down and being cleaned, so she did not receive anything to eat. Staff interviews corroborated systemic issues: a CNA reported problems with residents being fed at dinner due to meal carts arriving during shift change, an LPN reported residents (including the first two residents) complaining they had not been fed or had not eaten, and the dietary manager described communication failures about residents leaving and returning to the facility, resulting in meal tickets not being printed and residents not receiving trays, without these issues being reported to the Administrator.
Failure to Provide Ordered Double Vegetable Portions
Penalty
Summary
The deficiency involves the facility’s failure to provide residents with proper portion sizes as ordered, in accordance with its own menu and nutrition policies. The facility’s Healthcare Services Group policy titled “Menus” states that menus will be planned in advance to meet residents’ nutritional needs, will use standardized recipes and nutrient analysis, and will be served as written unless substitutions are made and logged. Despite this, surveyors found that residents were not consistently receiving the ordered portions, specifically related to extra vegetable servings. Resident #91 had a diet order written for a consistent carbohydrate diet with regular texture, thin liquids, double vegetable portions, and large portions for breakfast. On review of the resident’s diet tray ticket on one observation date, the ticket did not specify double vegetable portions, and the resident had already finished the meal, so the actual portions could not be verified. On another observation date, the tray ticket again did not specify double vegetable portions, and the resident was observed receiving three potato wedges, the same amount as other residents, rather than an increased portion. The Dietary Manager acknowledged that orders for extra portions should appear on tray tickets so dietary staff are aware, and stated that this resident’s tray tickets previously included instructions for extra portions but no longer did, without knowing why this change occurred.
Failure to Provide Ordered Lunch Meal to Dependent, Visually Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received a nourishing, palatable, well‑balanced diet that met the resident’s nutritional needs. The resident had multiple diagnoses including Type II DM, hypothyroidism, hypokalemia, adult failure to thrive, and anxiety disorder, and was blind with impaired cognition (BIMS score of eight). The care plan documented ADL self‑care performance deficits related to impaired vision and arthritis, required staff assistance with meals, and specified that staff should help the resident eat, encourage self‑feeding when possible, and use the clock system to describe plate setup. The resident was also care planned as being at risk for nutrition and hydration deficits due to multiple medical conditions and diuretic use, with interventions including providing ordered supplements and monitoring intake and weight. Facility documentation identified the resident as requiring feeding assistance. On the observed lunch meal service date, surveyors noted that the resident was in her room at 11:39 A.M. with no meal tray present. Hall trays were delivered to the hallway at 11:52 A.M., and to resident rooms by 11:58 A.M., yet from 12:02 P.M. through 12:40 P.M. the resident still did not have a lunch tray. A CNA interviewed at 12:45 P.M. stated she was unaware the resident had not received a lunch tray, explained she was unfamiliar with the residents and the facility’s lunch tray process because it was her first time in the facility, and confirmed she did not check to ensure all residents had their lunch trays. An RN interviewed at 12:49 P.M. stated the resident always refuses meals and was not offered a tray because the resident likes Cheerios, further stating the resident would not allow a plate to sit on the tray table and again confirming that lunch was not offered to the resident.
Failure to Provide Evening Meal to Newly Admitted Resident
Penalty
Summary
The facility failed to provide an evening meal to a newly admitted resident whose diagnoses included fracture of the pelvis, respiratory failure, and protein-calorie malnutrition. The resident was admitted to the facility in the early evening with a physician’s order for a regular diet with mechanical soft foods. According to the resident’s family member, they arrived at approximately 5:55 P.M., and no staff offered or brought any food to the resident. The family member reported seeing only one nurse, who stated the kitchen was closed for the day, leading the family member to go to a local restaurant to obtain food for the resident. The resident later stated that they were hungry, did not get much to eat for supper, and that their daughter had to bring food because the facility did not provide a meal tray. The Dietary Manager reported that they are notified of expected admissions via memo and that on the day in question they had prepared three or four meal trays for anticipated admissions, including a tray intended for this resident. The Dietary Manager explained that they must wait for nursing to enter the resident’s information into the EMR before entering diet information into the dietary system, and that if a resident is admitted before 7:00 P.M., nursing is expected to inform dietary of the admission and ask the resident what they would like for the meal. On this occasion, dietary staff were not informed that the resident had arrived, so they left a tray in the kitchen window for nursing to take when the resident came in. The next morning, the tray was still in the kitchen window and had not been passed to the resident. The Dietary Manager stated this was not the first time such an occurrence had happened. The DON, Administrator, and Medical Director each indicated in interviews that they would expect new or late-returning residents to receive some type of nourishment, such as a meal tray or sandwich.
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